Euthanasia Consent Form EUTHANASIA CONSENT Today's Date Month Day Year Owner / Agent InformationWho is submitting this form?(Required) Owner Agent Name First Last PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Equine Patient InformationPatient Name Breed Color AgeSex Male Female GenderColtStallionGeldingGenderFillyMareBroodmare If the equine is insured, it is the responsibility of the owner/agent to inform the insurance company of the euthanasia and have them contact McKinley & Peters Equine Hospital for further details. If the insurance policy states that the treating veterinarian must contact the insurance company before euthanasia, please provide the requested information below. If a post mortem exam is required for insurance purposes, I hereby grant permission to the treating veterinarian to perform said exam and agree to pay all costs related to the post mortem exam. Insurance Company PhoneSignature SectionI, the undersigned, certify that I am the owner or duly authorized agent for the owner of the animal described above. I hereby give the doctors, agents, servants, and representatives of McKiniay & Peters Equine Hospital full and complete authority to humanely euthanize said animal in a humane manner. Unless otherwise agreed upon, disposal of the body of said animal is left to the judgement of the veterinarian. I agree to pay all costs incurred in this procedure, including disposal costs. I also hereby, by signing this form, forever release the doctors, agents, servants, and representatives of McKinlay & Peters Equine Hospital from any and all liability for so euthanizing and disposing of said animal.Owner SignatureOwner Signature Date Month Day Year Agent Signature(If signing as Agent of the Owner, the undersigned warrants that he/she has authority to bond the owner.)Agent Signature Date Month Day Year Witness SignatureWitness Signature Date Month Day Year Equine Patient Veterinarian CAPTCHA Δ
